Basic Information
| Provider Information | |||||||||
| NPI: | 1346432572 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DENBO | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 176 CRESTMERE PL | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381123202 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2450 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554541450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126726000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2007 | ||||||||
| LastUpdateDate: | 01/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | Q1587 | TX | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2086X0206X | 62506 | MN | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 343113201 (MDACC) | 05 | TX | MEDICAID | 8ET732 (MDACC) | 01 | TX | BCBS | OTHER |